EXHIBIT 3.11. Coping With Craving: A Structured Coping Skills Training Exercise⁹²⁷

Overview

This exercise is designed for a group format but can be adapted for an individual session. It is 60 minutes long^* and divided into segments of roughly 20 minutes each.

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Check-In. Elicit the clients' current concerns, general level of functioning, substance use, experiences of craving and situational triggers in the past week, and experiences with practice exercises or challenges from the previous week.

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Introduction of Coping Skills. Introduce the topic. Lead an interactive discussion of what craving is and how to cope with cravings and triggers to use or engage in risk behaviors.

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Practice Skills. Practice coping skills identified in the session, leave time for discussion of the experience and the session, and provide a between-sessions practice exercise.

Session Goals

Cravings and situational cues that trigger impulses to engage in risk behaviors can be disturbing and confusing to clients. Some people who have SUDs, for example, can experience cravings weeks and even months after stopping use. Impulses to engage in risk behaviors can seem like they come out of the blue. The goals of this session are to:

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Offer information about the nature of craving; describe it as a normal, time-limited event that may or may not result in a recurrence of problematic substance use.

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Understand each client's belief about and experience of craving or impulses to engage in risk behaviors.

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Work collaboratively with clients to identify craving cues and situational triggers.

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Describe and practice craving and impulse-management coping skills.

Key Interventions

Understanding the Nature of Craving

Counselors can elicit a client's understanding of craving with an open question such as, “What do you know about cravings to use alcohol or drugs and why people have them?” Offer information about how the brain adapts to having a particular substance in the body over time and how, when the substance is taken away, the body reacts with a physical craving (similar to a hunger pang) that tells the brain it “needs” the substance to quiet the discomfort. Unlike food, the body doesn't need substances to survive, but the brain is tricking the body into reacting as if it does.

Counselors should consider giving a brief description of cue conditioning by using the example of Pavlov's dog. Pavlov trained the dog to salivate when a bell rang; the dog had learned to recognize the bell as a cue that it was about to get food. Any number of cues get paired with the desire to use substances or the impulse to engage in risk behaviors, such as seeing a pipe, needle, or beer mug or hearing the ring tone of a former drug dealer. Once these situational cues are identified, the experience of craving or sudden impulses to engage in risk behaviors becomes more understandable and less of a mystery for clients. This can help them learn to tolerate the discomfort, until the craving subsides.

Normalizing cravings is also important. Counselors can help clients understand that experiencing a craving is not a deficit on their part, and describe the time-limited nature of cravings and impulses. Most cravings last 7 to 20 minutes. The intensity may increase and decrease several times during that period. Eventually, the craving dissipates. Counselors can draw a series of bell curves on a flip chart or use a handout as a visual aid to demonstrate this. Also explain that cravings decrease in frequency and intensity with continued abstinence. After reviewing this information, ask clients what they make of it and how it may have changed their understanding of cravings.

Elicit Clients' Experiences of Craving

Counselors should elicit their client's experiences of cravings and how they have coped with cravings in the past. Introduce this by noting that people experience cravings in different ways, and then say, “Let's explore what cravings are like for you.” Questions counselors can ask are:

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How do you experience craving? Is it mostly a physical sensation like your heart racing, a sick feeling in your stomach, or maybe a headache? Is it more like your brain tells you things, such as: “I gotta have it now”? Or do cravings show up when you feel a certain emotion, like anger or boredom?

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How long does a typical craving last for you?

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How upset are you about the craving? Does it roll off your back, or does it take over?

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What do you do to cope with craving when it shows up?

Identify Situational Cues and Triggers

Make a list of situational cues and triggers with clients. Counselors can use a flip chart or whiteboard or have a handout in which people can write down their specific triggers in each category. Introduce this exercise by stating, “Let's start a list of the specific situations and cues that trigger cravings for you. Let's focus on your most intense triggers over the past few weeks.” Feelings associated with cravings can be positive or negative.

Help Clients Identify and Learn Coping Skills

Introduction to clients: “The overall strategy for coping with cravings is ‘recognize, avoid, and cope.’ Identifying cues and triggers is the first step. The best way to deal with craving, especially early in recovery, is to avoid situations where you're likely to experience cues and triggers. For example, get rid of drug paraphernalia and materials related to substance use, break off contact with people who deal and use drugs, and avoid high-risk places. You can't avoid every trigger, so the final step is to use coping strategies you already use to manage cravings and to learn some new ones. Here are some coping strategies that have worked for others; let's discuss them and add your ideas about what has worked or might work for you.”

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Look for distraction. Clients can try taking a walk, playing a game, or reading for relaxation.

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Talk through the craving with a supportive ally, such as a peer specialist or 12-Step sponsor. Counselors can suggest that clients find one or two safe people to talk to about cravings when they happen; recommend choosing people who will listen, rather than judge or criticize. Invite clients to list a few such recovery support people.

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Externalize the craving. Have clients talk about “the craving” instead of “my craving.” Ask them to imagine it shrinking in size and power and moving off to the side of their awareness, so it is not so overwhelming.

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Go with the craving. Clients don't need to repress the craving. Counselors should allow them to recognize it, take a couple of deep breaths, and remember that it will pass.

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Remember the negative consequences of substance use and the positive reasons for pursuing the chosen recovery pathway. Counselors should ask clients to brainstorm. Pass out two cards, one marked “Reasons for Staying in Recovery” and the other marked “Negative Consequences of Substance Use.” Counselors should have clients write down three to five items on each card, then instruct them to keep the cards handy and read them when a craving shows up.

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Talk through cravings. Challenge automatic thoughts (e.g., “I won't die if I don't smoke crack”), and normalize the craving (e.g., “The craving is uncomfortable, but it's okay; I can ride it out without using,” or “A craving is just a craving; it's not who I am.”).

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Come up with client-generated strategies. Lead clients in brainstorming about specific coping strategies that are acceptable, accessible, and appropriate for each of them. Pass out blank cards and invite clients to write down five to eight specific coping strategies that they can practice at home.

Practice Coping Skills

Counselors can pick one coping skill from the list that can be practiced in session and engage clients in an experiential exercise for 5 to 8 minutes. This gives them an opportunity to practice a new coping skill and anticipate obstacles that may arise when using it in everyday life. For example, invite clients to pair up with a partner and take turns talking through a craving. Instruct the listener to refrain from giving advice, but just listen and offer an affirmation to the storyteller about his or her efforts to talk through the craving instead of using a substance. Discuss the exercise and offer clients a practice exercise to work with until the next session.

Assign Between-Session Exercises

An important element of CBT is giving clients between-session challenges to identify and monitor distorted thinking and the feelings and impulses linked to thoughts, and to evaluate the effectiveness of coping skills learned in session. The goal of this exercise is to help clients develop a deeper understanding of the links between thoughts, feelings, and the impulse to use substances or engage in risk behaviors. In addition, it provides an impetus for clients to practice coping skills learned in session and to evaluate their effectiveness.

Monitoring Temptation and Evaluating Coping Skills

Introduction to Client

“Temptation is a strong desire made up of thoughts, feelings, impulses to act, and physical sensations—like a craving to use alcohol or drugs. Looking more closely at times when the temptation to use [name the substance] is strong can help you identify the specific tricks your mind uses to try to lure you into using substances and how feelings and impulses are closely linked to your thoughts. This exercise will help you keep track of the thoughts, feelings, and impulses that you experience when you feel a temptation to use [name the substance]. It will also give you a chance to practice some coping strategies you have learned and to see how well they are working.”

Instructions to Client

“During a typical day, jot down what you were feeling and thinking at times when you felt a craving and were tempted to use [name substance]. Make note of what the situation was and how you managed not to act on the impulse. Practice one or two of the coping skills you learned in this session. If you want, keep a pad with you during the day to make notes and then fill out this form at the end of the day. The form includes some questions you can ask yourself that may be helpful to you.”

“Please rate the intensity of the craving, feeling, and impulse to act on a scale of 1 to 10, 1 being not very intense and 10 being extremely intense. This will help us get a sense of when the temptation is strongest. Also, please try to rate the effectiveness of your strategy for managing the impulse to act on a scale of 1 to 10. This will give us a sense of which coping strategies are working well and which ones may not be as effective. Any questions?”

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Depending on group size and type of participants (e.g., clients with a single SUD, clients with multiple SUDs, clients with CODs), this exercise may need to be divided into two sessions.

Source: Adapted from the Substance Abuse and Mental Health Services Administration. (2019). Enhancing motivation for change in substance use disorder treatment. Treatment Improvement Protocol (TIP) Series 35. SAMHSA Publication No. PEP19-02-01-003.